2.2 What Ralph Taught Us About TMS

Abstract

Background: In 2005, an important paper came out, reporting on substantial decrease in hallucinations after using magnetic stimulation to the language areas. This effect was brought about in patients who were resistant to all types of antipsychotic medication, even to clozapine—a group that is suffering from hallucinations for many years. This article really gave hope to those experiencing resistant voices and to the people treating them.Methods: In a series of randomized placebo (or transcranial magnetic stimulation [TMS])-controlled trials, the Utrecht team further explored this technique in medication-resistant patients. We performed 5 trials: -1Hz rTMS versus placebo versus functional magnetic resonance imaging (fMRI)-guided 1Hz rTMS, -1Hz fMRI-guided rTMS versus 20Hz fMRI-guided rTMS, -priming rTMS versus standard 1Hz rTMS, -thetaburst rTMS versus placebo, and -direct current stimulation versus placebo. These studies were performed in samples of approximately 60 patients.Results: In all RCTs, a minority of some 10% responded favorable to focal stimulation. Given the response also present in the placebo group, the differences never became significant.Conclusion: Despite the hopeful first reports, we are thus far not able to demonstrate a significant effect of focal stimulation techniques for hallucinations. Despite the absence of scientific proof, several patients have been helped substantially, and we keep them free of voices by providing booster sessions of focal stimulation every 3 months. In sum, it is to early to give up this method, as it is safe and easy applicable and has been shown effective in other labs.